Do you really understand your employer's group health plan?

• Are you unhappy with your current health plan?

• Did you just turn 26 and get kicked off your parents’ plan?

• Are you self-employed or thinking about cutting the corporate cord?

• Are you retired but under 65, waiting for Medicare to kick in?

This blog will challenge you to consider the Individual health plan and look more closely at exactly what you are getting for the premiums (which keep increasing) associated with your group plan.

I come from the insulated and uninformed world of the highly coveted Group plan that many employers offer their employees. Because I was in the Group plan for all of my adult life, I never even knew Individual plans existed. I actually felt sorry for people who had these “individual” plans. I assumed they were junk. I couldn’t have been more wrong.

My biggest fear in losing my job was losing my health plan. I assumed the Group plan was the best and most supreme plan in the universe, until I came upon the Individual plan. The more I learned about it, the more intrigued I became. I started asking people in Group plans what they knew about their costs and benefits. Most knew very little: the premium and the co-pay for the doctor or ER visit. I also asked friends with Group plans what their premiums were. I could then get them a quote for an Individual plan that in most cases was cheaper and offered so much more. I also came across people who looked at me like I was an alien even considering such blasphemy. What me, leave my cushy Group plan? They thought I was crazy. But I knew my Group plan premiums and co-pays were increasing every year. I started asking, why? Does this sound familiar? I rarely went to the doctor. I remember when I had a $0 co-pay and paid no premium to my employer. Those days are long gone. Recently my co-pay went up to $30 along with the premiums. I wasn’t being allowed to benefit from my rare use of the plan. Shouldn’t I pay less if I use less? Shouldn’t I be rewarded for being a wise consumer, or a healthy person? Why did I have to use the affiliated hospital for x-rays, MRIs etc? Couldn’t I find a cheaper place to have an MRI done and be compensated for my thrifty ways?

If I had to predict the future of Group plans, I would say they will get too expensive for employers to offer. The employer will need to raise premiums and the plans will offer less and have higher co-pays. A one size fits all is too costly and provides no incentives for the members of the plan for being healthy or wise. The Individual plan will become the norm in the next few years IMO. Medical expenses are just going up too far and too fast. People can’t afford to be sick. Some can’t even afford the premiums. The way I see it is if I’m not dead, then it costs money to be alive. Since I prefer to be alive, why not shop for a more efficient Health care plan?

Most people will benefit from an Individual plan. These plans are not just for 26 year olds who suddenly need coverage, or independent contractors and the self-employed. People 60-64 waiting for Medicare are also great candidates for a peek into the Individual market. Seniors using Medicare Advantage plans also should consider using Individual Supplemental plans. But actually there may be a huge number of Group plan holders who would benefit from an Individual plan and don’t even know it. They may be paying too much premium and getting too little in return from their plans and should consider replacing their group plan with an Individual plan they can grow with and save even more money. (I can explain this in more detail when we hopefully meet).

I know it is difficult to think outside the box and “group think” is difficult to overcome, but at least you should take my challenge and investigate the prices and options an Individual plan offers. What have you got to lose? Put the remote down and invest some time in you. Pause your temporary numbness from watching Netflix. Don’t you shop for deals on food, gas, shoes, cars, and more? Why not shop for your own Individual health plan?

How would you like the following?

1. Choice of doctor

2. Specialist w/out referral

3. Choice of deductible

4. Choice of coverage level

5. Getting paid back for being a wise consumer of heath service

6. Having more coverage than you are getting now

7. Paying less premium

8. Having an advocate for you

9. Having access to “teledoc”

10. Discount prescriptions

There are other advantages, as well, but the one that jumps out the most is being paid for being wise. I will illustrate this from part of a brochure I use with clients. The main idea here is picking the plan that meets your personal needs, selecting the options you are most comfortable with, and in some cases being paid back for any services you use. Below you will see the amount of benefit a plan pays out for a doctor’s visit, or a specialist visit, along with how many are allowed per year, per insured. If the policy holder chooses the PLUS plan (middle column in the table below) the policy pays a benefit of $120/visit. If the consumer can find a lower rate, then the consumer actually gets paid for that visit. If you need an MRI in the PLUS plan you get a benefit of $500. If you are wise and go to an independent imaging center and pay $350, you again get paid for that MRI.

As you can see from the outpatient services the plan pays policy holders a set BENEFIT amount. If policy holders are disciplined and shop around, they can actually get paid for procedures. You have to shift your paradigm. The Individual plan pays a benefit. There is no “man behind the curtain.” I hate the “man behind the curtain” in all aspects of life, but it is so much a part of the Health care world that we all just turn a blind eye to it and keep accepting these thinner and more expensive group plans. Get used to the idea of “benefit.” It changes everything.

Here is another part of the plan that illustrates a stay overnight in a hospital and what the plan’s benefit is:

The average cost for a stay in the hospital is just under $2000/day. If you had the PLUS plan, it would pay a benefit of $3000/day - if in ICU, $4,500/day.

I hope you are seeing the value these Individual plans offer and will contact me to get you a quote. These plans do require underwriting and have limitations for pre-existing conditions. Also, they do not cover pregnancy. There are ways around both of these issues. If you are relatively healthy, go to the doctor a few times a year and are unhappy or concerned with your current plan and want to do some shopping, get in touch with me so we can do a side-by-side comparison. Maybe you don’t currently have a plan. Contact me, and I can show you affordable plans.